Cava Thrombus Research Articles

Thrombus burden, caval thrombosis, and retrieval of the Denali inferior vena cava filter

The study purpose was to evaluate Denali IVC filter (Bard Peripheral Vascular, Tempe, Arizona) outcomes. Five hundred patients had 508 filters placed between 2015 and 2022. Filters were retrieved at the study site in 284 patients, 159 (31.4%) were deemed permanent, 21 (4.1%) were retrieved at an outside hospital, 27 (5.3%) had outside hospital follow-up without known retrieval, and 17 (3.3%) were lost to follow-up. Initial retrieval at the study site was successful in 275 cases while 7 cases had successful second retrieval attempts (99.3% overall success). Initial retrieval venogram showed clot in filter in 18/284 (6.3%) and an occluded cava in 12/284 (4.2%). Contrast enhanced imaging was available in 79 patients without study site retrieval: 7/79 (8.9%) had thrombus within the filter, 7/79 (8.9%) had caval thrombosis/occlusion/severe stenosis, and 1/75 (1.2%) had new nonocclusive caval thrombus. No filter fracture, clinically significant extravascular strut penetration, or migration was reported.

Management and Outcomes of Wilms Tumor With Suprarenal Intravascular Extension: A Pediatric Surgical Oncology Research Collaborative Study.

The purpose of this study was to describe management and outcomes from a contemporary cohort of children with Wilms tumor complicated by inferior vena caval thrombus. The largest series of these patients was published almost 2 decades ago. Since then, neoadjuvant chemotherapy has been commonly used to manage these patients, and outcomes have not been reported. Retrospective review of 19 North American centers between 2009 and 2019. Patient and disease characteristics, management, and outcomes were investigated and analyzed. Of 124 patients, 81% had favorable histology (FH), and 52% were stage IV. IVC thrombus level was infrahepatic in 53 (43%), intrahepatic in 32 (26%), suprahepatic in 14 (11%), and cardiac in 24 (19%). Neoadjuvant chemotherapy using a 3-drug regimen was administered in 82% and postresection radiation in 90%. Thrombus level regression was 45% overall, with suprahepatic level showing the best response (62%). Cardiopulmonary bypass (CPB) was potentially avoided in 67%. The perioperative complication rate was significantly lower after neoadjuvant chemotherapy [(25%) vs upfront surgery (55%); P =0.005]. CPB was not associated with higher complications [CPB (50%) vs no CPB (27%); P =0.08]. Two-year event-free survival was 93% and overall survival was 96%, higher in FH cases (FH 98% vs unfavorable histology/anaplastic 82%; P =0.73). Neither incomplete resection nor viable thrombus cells affected event-free survival or overall survival. Multimodal therapy resulted in excellent outcomes, even with advanced-stage disease and cardiac extension. Neoadjuvant chemotherapy decreased the need for CPB to facilitate resection. Complete thrombectomy may not always be necessary.

Feasibility and safety of some surgical maneuvers during vena cava thrombectomy in patients with intravenous spread of renal cell carcinoma

The aim of the study is to analyse the feasibility and safety of some complex surgical manoeuvres during vena cava trombectomy.Material and Methods. The study included 78 (62.9%) men and 46 (37.1%) women. The average age of patients was 58.4±10.5 years. There were right-sided tumours in 82 (66.1%) cases and left-sided tumours in 42 (33.9%). Caval thrombi were of levels I, II, II, and IV, respectively, in 35 (28.2%), 36 (29%), 27 (21.8%) and 26 (21%) observations. All operations were performed without the use of artificial circulation. Results of the study. Liver mobilization was technically difficult in 17.8% of observations and was accompanied by 17 (37.8%) intraoperative complications in 13 (28.9%) patients. The most severe complications were injuries to the hepatic parenchyma (11.1%) and the main hepatic veins (11.1%). Access to the supra-diaphragmatic section of the LAA and the right atrium was feasible in all observations with an intraoperative complication rate of 8.8%. No damage to the right diaphragmatic nerve was noted in any of the observations. The right pleural cavity was opened in 2 (5.9%) patients with atrial thrombi. Another patient (2.9%) had damage to the posterior wall of the inferior vena cava at the level of its intrapericardial segment. Thrombus apex palpation and milking maneuver were successful in 83.1% and 90% of patients, respectively.Conclusion. Removal of tumour thrombi from the IVC for renal neoplasms is a complex surgical intervention. It requires the use of a large number of special surgical manoeuvres and techniques, which are difficult to perform in 10% of patients and may be accompanied by severe intraoperative complications.

Is Continuous Wound Infiltration a Better Option for Postoperative Pain Management after Open Nephrectomy Compared to Thoracic Epidural Analgesia?

Despite increasingly advanced minimally invasive percutaneous ablation techniques, surgery remains the only evidence-based therapy in curative intent for larger (>3-4 cm) renal tumors. Although minimally invasive surgery using (robotic-assisted) laparoscopic or retroperitoneoscopic approaches has gained popularity, open nephrectomy (ON) is still performed in 25% of cases, especially in tumors with central localization (partial ON) or large tumors with/without cava thrombus (total ON). As postoperative pain is one of the drawbacks of ON, our study aims to assess recovery and post-operative pain management using continuous wound infiltration (CWI) compared to thoracic epidural analgesia (TEA). Since 2012, all patients undergoing ON at our tertiary cancer center at CHUV have been included in our prospective ERAS® (enhanced recovery after surgery) registry that is centrally stored in ERAS® Interactive Audit System (EIAS) secured server. This study represents an analysis of all patients operated on with partial or total ON at our center between 2012 and 2022. An additional analysis was performed for the estimations of the total cost of CWI and TEA, based on the diagnosis-related group method. 92 patients were included and analyzed in this analysis (n = 64 (70%) with CWI; n = 28 (30%) with TEA). Adequate oral pain control was earlier achieved in the CWI group compared to the TEA group (median 3 vs. 4 days; p = 0.001), whereas immediate postoperative pain relief was better in the TEA group (p = 0.002). Consequently, opioid use was higher in the CWI group (p = 0.004). Still, reported nausea was lower in the CWI group (p = 0.002). Median time to bowel recovery was similar in both groups (p = 0.03). A shorter LOS (0.5 days) was observed in patients managed with CWI, although this was not statistically significant (p = 0.06). The use of CWI has reduced total hospital costs by nearly 40%. TEA has better results in terms of postoperative pain management compared to CWI following ON. However, CWI is better tolerated, and causes less nausea and earlier recovery, which leads to a shorter length of stay. Given its simplicity and cost-effectiveness, CWI should be encouraged for ON.

Preemptively planned en bloc resection of an extensive right adrenal pheochromocytoma involving the right hepatic division, caval thrombus and segmental caudal vena cava in a dog with Budd−Chiari‐like syndrome

Surgical resection is the treatment of choice for canine adrenal pheochromocytomas (PHEOs). Information on en bloc resection of adrenal PHEO with tumour thrombus, right hepatic division and segmental caudal vena cava (CVC) running through the adrenal tumour and right hepatic division is limited. To describe the preemptively planned en bloc resection of an extensive right adrenal PHEO involving the right hepatic division, the caval thrombus and the segmental CVC in a dog with Budd-Chiari-like syndrome (BCLS). A 13-year-old castrated male miniature dachshund was referred for surgical treatment due to anorexia, lethargy and severe abdominal distension caused by abundant ascites. Preoperative computed tomography (CT) revealed a large mass in the right adrenal gland with a large caval thrombus obstructing the CVC and hepatic veins, which caused BCLS. Additionally, collateral vessels were formed between the CVC and azygos veins. No findings suggested obvious metastases. Based on CT findings, an en bloc resection of the adrenal tumour with caval thrombus, right hepatic division and segmental CVC was planned. The preoperatively planned resection was feasible; the tumour was completely resected grossly. The operation time and total Pringle manoeuvre time were 162min and 16min 56 s, respectively. There was no postoperative hindlimb oedema, renal dysfunction, ascites or abdominal distention. The patient's clinical signs, including appetite, fully improved. Hospitalization lasted 16 days. However, the patient died on the 130th postoperative day due to suspected metastases and cachexia. Even in case of an extensive infiltration of adrenal PHEO causing BCLS, an en bloc resection might be successfully achieved based on the preoperative CT findings speculating the collateral vessels formed for caudal venous return.

Prenatal diagnosis of a fetal inferior vena cava thrombus

Introduction: Diagnosis and management of fetal thrombosis during pregnancy is rare. Few cases of prenatally diagnosed inferior vena cava thrombi are reported and often occur with renal vein thrombi. Several maternal and fetal risk factors have been identified, including thrombophilias. Case Report: Patient is a 39-year-old G6P2123 with heterozygous Factor V Leiden with a prenatally diagnosed fetal inferior vena cava thrombus at 34 weeks of gestation during antenatal ultrasound. Her peripartum course was uncomplicated. On day 1 of life, neonatal ultrasound and computed tomography confirmed the presence of thrombus. On day 7, the neonate underwent a thrombectomy for definitive management due to risk of embolization. Conclusion: While ultrasound is not routinely used for screening for fetal thromboses, when thrombosis is diagnosed, antenatal management is complex, weighing fetal and maternal risks and benefits. Thrombectomy as definitive thrombus management is an appropriate treatment when risk of embolization exists. Imaging modalities are useful for both diagnosis and management of fetal thrombi.

Review of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy in Renal Cell Carcinoma.

Recent advances in minimally invasive technology have compelled surgeons to perform nephrectomy with inferior vena cava thrombectomy using robotic assistance. Here, we aim to review the data comparing open versus robot-assisted nephrectomy with IVC thrombectomy, as well as review operative robotic techniques for nephrectomy with IVC thrombectomy. Over the last decade, there have been increasing reports of successful robotic-assisted IVC thrombectomy among skilled robotic surgeons, with case series detailing operative technique, as well as operative and oncologic outcomes for levels I-IV caval thrombus. While there is immense promise in the future of robotic-assisted IVC thrombectomy, further studies with direct comparison to open surgical intervention will be needed to ensure the oncologic principles and outcomes are non-inferior.

Response to Neoadjuvant Chemotherapy and Outcomes in Children With Wilms Tumor With Caval Thrombus: A Single Center Experience.

The aim of our study is to present our experience in the management and outcome of Wilms tumor with intracaval thrombus. All children with Wilms tumor with intracaval thrombus who presented to us from July 2000 to December 2017 were reviewed retrospectively. We evaluated the tumor stage, management, and outcomes in these patients. Thirty-four patients were included in the study. The median age of presentation was 48 months (11 to 84mo). Preoperative chemotherapy was given in 32 (94%), with a median duration of 8 weeks. Intracaval thrombus completely resolved in 9 (26%) children after neoadjuvant chemotherapy. Surgical intervention for residual inferior vena cava (IVC) thrombus was performed in 32 patients. The median follow-up was 30 months (5 to 150mo). At the last follow-up, 24 patients (70%) were alive and disease free. The 5-year overall survival (OS) and event-free survival were 67% (95% confidence interval, 50% to 84%) and 59% (95% confidence interval, 42% to 76%). The OS in children with nonmetastatic disease (94%) was significantly higher than those with metastases (29%; P <0.01). The OS in children with complete resolution of IVC thrombus (100%) was significantly higher than those with persistent thrombus (48%; P =0.025). Analysis of survival outcomes in children with nonmetastatic disease (stage III) revealed no significant difference on comparison with cohort with stage III disease with absence of IVC thrombus. The P -value was 0.224 and 0.53 for 5-year OS and event-free survival, respectively. The management of Wilms tumor can be complicated by the presence of caval thrombus. Patients with metastasis have a significantly poor outcome. Patients in whom, there is complete resolution of intracaval thrombus on neoadjuvant chemotherapy have a significantly higher OS.

Cognitive Function After Cardiopulmonary Bypass and Deep Hypothermic Circulatory Arrest in Management of Renal Cell Carcinoma With Vena Caval Thrombus

ObjectiveTo compare cognitive outcomes of patients undergoing open radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy with vs without cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. Patients and MethodsA prospective, 6-month, observational study was conducted from January 2013 to December 2019 in renal cell carcinoma patients with level II-IV IVC thrombus undergoing RN. A battery of standardized neuropsychological tests was administrated to assess multi-domain cognitive function before surgery, 1 week, and 6 months after surgery: attention, executive functions, working memory, short-term and long-term delay recall, visuomotor speed, and verbal fluency. ResultsCognitive impairment was defined as a 20% reduction in at least 20% of the main variables. The primary outcome was the incidence of cognitive impairment at 6 months postoperatively and was analyzed with general linear mixed models. Twenty-six patients treated with CPB and 39 treated with non-CPB were analyzed. There were no significant differences in cognitive impairment between the two groups. The incidence of cognitive impairment at 1 week postoperatively was 38.5% in CPB group and 30.8% in non-CPB group (P = .52), after 6 months 11.5% and 10.3% (P = 1.00). Multivariate analysis indicated that the estimated blood loss was the only risk factor associated with cognitive impairment at 1 week postoperatively. ConclusionThis study showed no significant differences in postoperative cognitive function of renal cell carcinoma patients after open RN and IVC thrombectomy with and without CPB and deep hypothermic circulatory arrest. Estimated blood loss was found to be associated with cognitive impairment at 6 months postoperatively.

Metastasis of breast cancer to the right kidney with a tumor thrombus in the inferior vena cava: a case report

BackgroundIt is quite rare for breast cancer to metastasize to the kidney with a tumor thrombus in the inferior vena cava.Case presentationA Japanese woman in her forties was diagnosed with cancer of the left breast and underwent left mastectomy with sentinel lymph node biopsy. The final pathological diagnosis was pT1aN0M0, stage IA (ER positive, PgR positive, HER2 negative). Thirteen years later, she presented for care with the complaint of abdominal pain. By imaging findings, right renal carcinoma with a tumor thrombus in the inferior vena cava and lung metastases was suspected. However, her tumors were refractory to molecular targeted therapy. In addition, CT-guided needle biopsy of the kidney and lung lesions was done and it was revealed that lesions of the left lung and the right kidney was breast cancer metastases (ER positive, PgR positive, HER2 negative). The patient started combination therapy consisting of abemaciclib, tamoxifen and leuprorelin. Six months later, she died from progression of her metastatic disease.ConclusionsIt is sometimes difficult to differentiate between primary renal cancer and kidney metastases from breast cancer on imaging. Renal biopsy is recommended before commencing treatment.

Oncological Outcomes of Primary Renal Malignancies other than Clear Cell Renal Carcinoma: A Retrospective Study from a Tertiary Centre in Southern India

Introduction: A lot of research is available about clear cell Renal Carcinomas (ccRCC). But there are lesser known facts about other subtypes of renal malignancies. With advances in immunohistochemical and cytogenetic techniques, new variants of renal tumours are being increasingly reported. The treatment and prognosis of such rare malignancies is still an enigma. Aim: To analyse the incidence, clinicopathological features, surgical treatment, and survival of non clear cell RCC at the tertiary care centre. Materials and Methods: The present study was a retrospective study in which histopathological reports of 77 nephrectomy specimens who underwent surgical treatment for suspected renal tumours from 2013-2018 were reviewed. Of which 19 (24%) patients had documented uncommon histologic variants of RCC. The clinical, demographic, and histologic characteristics of these patients were analysed, and survival was evaluated. The characteristic light microscopy and immunohistochemical features of these lesions were documented. Results: Mean age was 45 years (21-67 years). Out of 19 patients, 14 (73.6%) were males, and 5 (26.4%) were females. Mean tumour size was 8.8 cm (range 6-36) in the largest dimension. About 17 (22%) patients underwent radical nephrectomy, and 2 (2.5%) were treated with partial nephrectomy. Patients with collecting duct, synovial sarcoma, and primitive Neuroectodermal tumour (PNET) had associated inferior vena caval thrombus and underwent venous thrombectomy. Adjuvant treatment in the form of chemotherapy was instituted in collecting duct, adult Wilms and pure sarcomas. There was no mortality in the papillary carcinoma, and the worst prognosis was encountered in collecting duct carcinoma. Conclusion: Papillary variant had a good outcome as compared to other non clear cell carcinomas. RCC with sarcomatoid variant has a poor prognosis. Variants like renal sarcomas are rare but can be managed by nephron sparing surgeries with adjuvant therapies.

Budd-Chiari syndrome: An unusual complication of an internal jugular tunneled dialysis catheter.

Budd-Chiari syndrome due to the tip of an internal jugular tunneled dialysis catheter malposition in inferior vena cava or hepatic vein is a rare complication. We aimed to present our experience and compare it with the previous reports to highlight the clinical features and the optimal management. A 57-year-old female with history of ANCAp vasculitis, treated by hemodialysis in the last 2 years on a right internal jugular vein tunneled catheter was admitted for pain in the right upper quadrant. A subacute Budd-Chiari syndrome due to catheter malposition was diagnosed. The catheter was removed, and a new tunneled hemodialysis line was inserted in the right internal jugular vein with the tip at the junction of right atrium with superior vena cava. Anticoagulation with apixaban 2.5 mg twice daily was started after catheter replacement and the patient was discharged. At 1 month follow-up the patient had no symptoms, and the ultrasound revealed the absence of the thrombus in the inferior vena cava. Imagining monitoring for malposition after insertion or in a clinical context suggestive for Budd-Chiari syndrome is essential for early diagnosis and treatment. In our case, anticoagulation with apixaban and prompt catheter replacement resulted in Budd-Chiari syndrome resolution.

Abstract 17133: Complete Inferior Vena Cava Thrombosis In A Sickle Cell Patient With Suspected May Thurner Syndrome

Case Presentation: 19 year old woman with sickle cell anemia and nephrotic syndrome presented with leg and back pain. While treated for vaso-occlusive crisis, patient developed dyspnea and chest pain. She underwent CT chest which revealed a right lower lobe pulmonary embolism. The patient was started on anticoagulation. Her transthoracic echocardiography revealed normal right heart function but nearly occlusive inferior vena cava (IVC) thrombus just distal to the right atrium. Subsequently a CT venogram demonstrated extensive thrombus from the left external iliac vein to the right atrium as well as compression of the left common iliac vein. Multidisciplinary discussion was performed to discuss options including medical therapy, surgical removal, or catheter-based removal. Given concern for further pulmonary embolization, patient underwent catheter based thrombus removal. A 26 french access was obtained in the right internal jugular vein and a 17 french access was obtained in the right femoral vein. Using the Angiovac system, mechanical thrombectomy was performed in the IVC. The angiovac system is a 24 french suction catheter with filtration and reperfusion through the right femoral vein. Limited thrombus removal was achieved. Next,14 french left femoral vein access was obtained and the Inari Clottriever device was used to mechanically score and remove a significant amount of thrombus (Figure 1). Post removal angiography revealed a patent IVC with minimal residual thrombus. Discussion: IVC thrombosis is a rare presentation of venous thromboembolism (VTE). This patient had multiple reasons for VTE including nephrotic syndrome and likely May Thurner Syndrome (MTS). MTS is an underdiagnosed entity resulting in mechanical compression of the left iliac vein in upto 50% of patients presenting with left lower extremity VTE. While proximal extension of thrombus is rare as seen in this case, high clinical suspicion is warranted for accurate diagnosis and treatment.

Radical nephrectomy and vena caval thrombectomy with the use of cardiopulmonary bypass and hypothermic circulatory arrest: Experience at a large tertiary institution

Objective: This study aimed to review the experience at a large regional tertiary centre of open radical nephrectomy (RN) with vena caval thrombectomy with cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA) for the management of renal masses. Method: Data on patients with renal masses who had undergone RN and vena caval thrombectomy with CPB and HCA had been prospectively collected at two centres over a 19-year period (2000–2019). Twenty-three consecutive patients were identified and retrospectively analysed for operative and tumour characteristics and for postoperative outcome. Kaplan–Meier survival analysis was performed to compare patient outcomes based on tumour characteristics. Results: Median operating time was 358 minutes (interquartile range (IQR)=94 minutes), median bypass time was 117 minutes (IQR=28.5 minutes) and median circulation arrest time was 25 minutes (IQR=18.5 minutes). The median hospital length of stay was 11 days (IQR=5.3 days). Total complication rate was 52% ( n=12), consisting of four minor and eight major complications (Clavien–Dindo score &gt;IIIa), including one intraoperative death. The overall five-year survival rate was 73% (11/15), with a median follow-up time of 53.1 months. Eleven (48%) patients were surgically cured, with a median follow-up time of 60.1 months (IQR=71.8 months). Disease recurrence was seen in eight (35%) patients, of whom four died. Patients who died survived for a median of 46.5 months. Median survival after the diagnosis of metastatic disease was seven months. Conclusions: We report the largest Australian cohort of RN with vena caval thrombectomy with CPB and HCA. We demonstrate outcomes comparable to major overseas centres, with an overall five-year survival rate of 73%. This suggests that even patients with extensive venal caval thrombus from renal masses can experience long-term survival benefit from RN and venal caval thrombectomy. Level of evidence: Level 3.

CTCs detection from intraoperative salvaged blood in RCC\u2013IVC thrombus patients by negative enrichment and iFISH identification: a preliminary study

BackgroundIntra-operative cell salvage (IOCS) and leukocyte-depleted filter (LDF) are widely used and effective in saving blood. However, the safety issue concerning reinfusion of IOCS–LDF processed blood to renal cell carcinoma (RCC) patients with inferior vena cava (IVC) thrombus were inconclusive for fear of increased risk of cancer metastases. This study intends to analyze the circulating tumor cell (CTC) eliminating effect of IOCS–LDF in 5 RCC–IVC thrombus patients.MethodsA novel strategy integrating negative enrichment by immunomagnetic beads and immunostaining-fluorescence in situ hybridization with probes identifying aneuploid of 8 and/or 7 were used to detect CTCs from salvages blood. Blood samples were collected from 4 stages in each patient.ResultsOf the 5 RCC patients, the number of CTCs decreased (from 3, 4, 10, 7, 3, respectively, to all zero) after IOCS–LDF treatment. The triploid of chromosome 7 and/or chromosome 8 were most common karyotype for RCC patients with IVC thrombus. Tetraploid of chromosome 8 occurred in only one sample and no polypoid (number of chromosome > 4) were found.ConclusionIOCS–LDF might be a promising way of reducing of allogeneic product transfusion based on current preliminary outcome. More convincing conclusions are to be drawn with enlarged sample size and long-term follow-up for patients prognosis.

Circle or semi-circle hyper-intensity on T1 high-resolution isovolumetric examination (THRIVE) indicates the young age of experimentally induced caval thrombus.

To evaluate the age of caval thrombus that experimentally induced in swine by use of magnetic resonance imaging (MRI). Caval thrombus was experimentally created in 15 swine by autologous clot injection assisted with caval net knitting. Serial high-resolution MR images were obtained using magnetic resonance venography (MRV) and T1 high-resolution isotropic volume examination (THRIVE) sequences in a 3.0-T MR system at 1, 7, 14, 21, and 28days post model creation. At each time point, three pigs were sacrificed and the thrombotic vena cava was processed for histopathological examinations respectively. Caval thrombus was successfully induced in 15 pigs in group A. The signal intensity (SI) change of caval thrombus on THRIVE was age-dependent, with a typical sign of circle or semi-circle hyper-intensity at 7-day-old model while SI of thrombus was lower than that of muscle from day 14 throughout day 28. The histo-pathological findings revealed that RBCs-rich thrombus at day 1 without blue-stained particles, RBCs layers with infiltration of inflammatory cells and sporadically distributed blue-stained particles at 7-day-old thrombus. At day 14, 21 and 28, blue-stained particles became richer, coupled with formation of granulation tissue and fibrous tissue. The swine model in the study is good for age evaluation of venous thrombosis. The peripheral circle or semi-circle hyperintensity on THRIVE indicates the young age of caval thrombus in swine.

Management of locally advanced renal cell carcinoma

: With the increased use of cross-sectional imaging, renal masses are increasingly detected when they are still clinically localized. However, a large portion of patients still have locally advanced or metastatic disease at the time of diagnosis. This includes both locally invasive disease as well as vena caval thrombus extension. Currently, surgical management offers the only chance of cure for tumors with direct invasion into adjacent structures and vena caval thrombus. This chapter will discuss this management including the surgical approach and techniques in these procedures, which can sometimes require a multidisciplinary approach and even bypass. Though surgical management might present the only chance for cure, frail patients might not be suitable candidates therefore not benefit from invasive intervention. The role of cytoreductive nephrectomy in metastatic disease is uncertain in the immunotherapy era, though it may offer benefit to some patients with good-risk features. This chapter will discuss the treatment of locally advanced renal cell carcinoma, risk assessment to reduce unnecessary morbidity and mortality, the role of lymph node dissection, caval thrombectomy, renal mass biopsy, and the changing landscape with the advent of targeted therapy and immunotherapy.

Multidisciplinary surgical approach to renal cancer with vena cava invasion and pulmonary embolism

Renal cancer is unique for many reasons. One reason is that renal cell carcinoma can grow directly into the drainage veins of the kidney, which enter the inferior vena cava leading to the heart. This growth of tumor cells into the veins is called atumor thrombus and is alocally aggressive renal cancer. The present article informs about the experience of our cardiac surgery department together with the transplant surgery department in successful surgical removal of akidney with tumor, with invasion into the inferior vena cava, right atrium of the heart and pulmonary artery in two case reports. A32 years old female without significant history, with suddenly evolving dyspnea was urgently admitted to hospital. Her condition was suspected to be caused by pulmonary artery embolisation. The diagnosis was confirmed by CT scan which revealed unknown tumor mass of the right kidney and tumor embolisation in inferior vena cava and pulmonary artery. The patient was urgently operated by avascular surgeon and cardiothoracic surgeon. They successfully performed left radical nephrectomy and total thromboembolectomy of the tumorous masses from vena cava inferior and pulmonary artery. The postoperative course was without complications, postoperative CT revealed no residual masses, and the patient was discharged in agood condition from the hospital. A58 years old male with arterial hypertension suffered from orchiepididymitis. CT scan showed atumor of the left kidney with propagation of tumorous masses to inferior vena cava and pulmonary artery. In elective surgery the vascular surgeon and cardiothoracic surgeon successfully performed left radical nephrectomy with total thromboembolectomy of the tumorous masses from inferior vena cava and pulmonary artery. After surgery atemporary paralytic ileus and an episode of atrial fibrillation occurred. Both are common postoperative complications related to the given surgical procedure. Follow-up CT scan showed no residual tumor or thrombus in inferior vena cava and pulmonary artery. Echocardiography revealed persistent dilation of right compartments of the heart with good systolic functions of both ventricles. The patient was discharged from hospital in agood condition. Surgical removal of renal tumor and tumor thrombus - radical nephrectomy with tumor thrombectomy - can be acurative treatment and can ensure long-term survival of the patient. Depending on the extent of the tumor thrombus, these operations can be performed in different ways - mini-invasive, robotic or open. When open surgery is used, it is possible to perform the procedure with or without extracorporeal circulation (cardiopulmonary bypass - CPB) depending on the extent of the disease.

Intrahepatic cholangiocarcinoma with a tumor thrombus extending from the inferior vena cava to the right atrium: a case report

BackgroundVascular invasion involving a tumor thrombus in the inferior vena cava and/or right atrium is an unfavorable prognostic factor after intrahepatic cholangiocarcinoma resection. We report an intrahepatic cholangiocarcinoma case with a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium.Case presentationA 58-year-old man with epigastralgia was referred to our hospital after an emergent transcatheter arterial embolization was done following the radiological diagnosis of a ruptured hepatic tumor. The serum concentrations of carcinoembryonic antigen, carbohydrate 19-9, duke pancreatic monoclonal antigen type 2, and cytokeratin-19 fragments were elevated; meanwhile those of alfa-fetoprotein and des-γ-carboxy prothrombin were within normal ranges. A contrast-enhanced computed tomography scan showed a heterogeneously enhanced tumor, 13 cm in diameter, in the left lobe of the liver, enlarged lymph nodes along the lesser curvature of the stomach, and a tumor thrombus extending from the left hepatic vein via the inferior vena cava to the right atrium. We performed a left hemihepatectomy and tumor thrombectomy under total hepatic vascular exclusion to reduce the risk of sudden death. After dissection of the liver parenchyma along the left side of the middle hepatic vein, except for the left hepatic vein, the inferior vena cava just below the right atrium could be clamped by pulling down the left lobe of the liver toward the caudal side. The thrombus could be removed by incising the inferior vena cava under total hepatic vascular exclusion. Microscopic examination showed a tubular adenocarcinoma. Immunohistochemical staining was positive for cytokeratin-7, cytokeratin-19, and epithelial membrane antigen, but negative for arginase-1, glypican-3, and hepatocyte. The patient was pathologically diagnosed with an intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava. Adjuvant chemotherapy with tegafur/gimeracil/oteracil was administered for 1 year. The patient remained in good health without cancer recurrence for over 4 years after the operation.ConclusionAn aggressive surgical approach may be indicated for intrahepatic cholangiocarcinoma with a tumor thrombus in the inferior vena cava and/or right atrium to avoid the risk of impending death.

Incidentally Detected Asymptomatic Thrombus in the Inferior Vena Cava Thought to be Caused by Central Venous Catheterization for an Oral Surgical Procedure

Central venous catheterization (CVC) is a common procedure in the perioperative period, and thrombosis is one of the well-known complications of CVC. If the thrombus comes free from the vascular wall, it may cause serious problems such as pulmonary embolism. However, in some cases of inferior vena cava thrombosis, the patient has no symptoms, and thrombus is detected accidentally. A case in which asymptomatic thrombus in the inferior vena cava was incidentally detected following removal of the CV catheter after an oral surgical procedure is described.